Healthcare Provider Details

I. General information

NPI: 1528107372
Provider Name (Legal Business Name): CHRISTOPHER MERLE NYSTUEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR DEPARTMENT OF MEDICAL READINESS
FT CARSON CO
80913-4613
US

IV. Provider business mailing address

1650 COCHRANE CIR
FT CARSON CO
80913-4613
US

V. Phone/Fax

Practice location:
  • Phone: 719-524-7351
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC54117
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: